Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
The Center for Medicare & Medicaid Services (CMS) recently released a Press release article that detailed how successful the Medicare Shared Savings Programs saved Medicare more than 1.6 billion in 2021. The article explained how well the Accountable Care Organizations (ACOs), “which include doctors, hospitals, and other health care providers, collaborated to provide high-quality care to people with Medicare. This was done through in-person visits and telehealth services to provide high-quality care to their patients.” The article shows the importance of reporting the diagnosis codes to the highest level of specificity when treating patients and providing quality care.
Chronic Kidney Disease and End Stage Renal Disease falls under the HCC categories (136-138, and 184). However, the conditions may not be captured and reported accurately due to a lack of documentation of the disease process and an indication of the patient’s dialysis or kidney transplant status. This would result in querying the provider for clarification or coding of unspecified diagnoses.
In the outpatient setting, signs and symptoms can be used if a patient is still being worked up at the end of the visit with no definitive diagnosis. Per ICD 10 guidelines, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.” However, per guidelines, signs and symptoms can be coded until a confirmed diagnosis. A provider should be aware that coding guidelines are different in the inpatient setting as opposed to the outpatient setting when it comes to coding “probable, suspected, rule out, etc.
We cannot discuss HCC and Risk Adjustment for CKD and ESRD without mentioning M.E.A.T.; this is the acronym that coders, CDIs, and auditors use when educating a provider and analyzing a record. We look to see if providers’ documentation supports the diagnosis with the following;
M – Monitor and Manage the condition
E– Evaluate the condition
A – Assess the condition
T– Treat the condition
Per ICD-10 CM Official Guidelines, “The ICD-10-CM classifies CKD based on severity. The severity of CKD is designated by stages 1-5. Stage 2, code N18.2, equates to mild CKD; stage 3, codes N18.30-N18.32, equates to moderate CKD; and stage 4, code N18.4, equates to severe CKD. Code N18.6, End-stage renal disease (ESRD), is assigned when the provider has documented End Stage Renal Disease (ESRD). If both a stage of CKD and ESRD are documented, assign code N18.6 only.”
Chronic Kidney Disease patients’ stages can often change from one stage to the next slowly with time to End Stage renal disease, which will require dialysis or a kidney transplant. Not all stages of CKD may fall under HCC, but that does not mean that it should not be clearly documented and up to date in the record.
ICD-10-CM Official Guidelines also give clear direction on documentation requirements for patients with kidney transplants and reporting of their status, using code Z94.0 (HCC 183). “Patients who have undergone kidney transplants may still have some form of chronic kidney disease (CKD) because the transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate N18 code for the patient’s stage of CKD and code Z94.0, Kidney transplant status. If the documentation is unclear as to whether the patient has a transplant complication, query the provider.”
A Provider linking statement per the ICD 10 guidelines is also important in the diagnosis’s documentation and coding to the highest specificity level. “A causal relationship between CKD and Hypertension and CKD and Diabetes is presumed unless the provider states otherwise.” Depending on documentation, these conditions often require combination codes and “trumping” of the HCC categories.
Remember that guidelines and codes change yearly on October 1; all providers, coders, and billing staff should be aware of the changes so that documentation and codes continue to be reported correctly. Suppose a provider keeps the term M.E.A.T. in mind. In that case, they will often have all the needed documentation for the coder to code the encounter without many queries and capture the HCC accurately.
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Resources:
https://www.cms.gov/files/document/fy-2022-icd-10-cm-coding-guidelines-updated-02012022.pdf
https://www.kidney.org/atoz/content/gfr
Optum360. 2019 Risk Adjustment Coding and HCC Guide. Optum360, LLC 2018
Great explanation of the documentation needed n MEAT practice that is imperative for precise coding/consistent in patient’s MR. In addition, capture HCC.Thank you